Urology Coding Alert

Urologists who treat patients with triple mix have many billing options and often dont know which ones to exercise. By keeping abreast of carrier policies, urologists can receive proper reimbursement for the supply, teaching and injection of this medication.

Triple mix is a solution used by urologists to treat impotence. It consists of three medications: papaverine, phentolamine and alprostadil. When injected into the penis, it produces an erection for sexual intercourse. Used therapeutically, it is self-administered by the patient.

Coding Triple Mix

There are some coding challenges involved in getting paid for treatment with triple mix. First, insurance companies may not cover the medication itself. Scott Radle, business manager for Accent Urology, a two-urologist practice in St. Louis says, You have to first check with the patients insurance carrier and see if it is covered. If it is covered, it is under the pharmacy benefit, and you can bill for it that way. In general, it is easier just to bill the patient directly. We usually collect the money for the vial (of medication) up front from the patient, and then the patient can submit it under his pharmacy benefit.

But regardless of who is paying patient or insurance company you need to code it correctly for your records. The codes for the medication are J2760 (injection, phentolamine mesylate, up to 5 mg), J2440 (injection, papaverine HCL, up to 60 mg) and J0270 (injection, alprostadil, 1.25 mcg [code may be used for Medicare when drug administered under direct supervision of a physician, not for use when drug is self-administered]).

When the patient picks up the vial to take it home, there is not just one dose but 10 doses. Radle recommends billing out 10 units of each for the take-home vials.

For Medicare carriers that allow benefits, the injection and initial titrating dosage for erectile dysfunction must be billed to Medicare, explains Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services, a compliance, coding and reimbursement consultant based in Denver. After that, payment up front by the patient is suggested, says Page.

There are two basic ways to obtain the triple mix. One is to work with a pharmacist who will mix the combination to suit the urologist. Every urologist seems to prefer his or her own proportions of the three medications in the triple mix. We get it premixed from the pharmacist, Radle explains. Then, when the patient comes in to pick up his medication, there is no billing. The patient simply pays for the drug, and the encounter is complete.

The other method of obtaining the medication is to give the patient a prescription for the three separate drugs. The patient buys it at the drugstore and brings it to the urologists office where the physician mixes the medication and gives the vial back to the patient. This is the method used by Adult and Pediatric Urology Group of Maryland, says Stella Natarova, CPC, CCS-P, former director of compliance and reimbursement and now at Johns Hopkins University. With this method, the nurse discusses the treatment with the patient. Use evaluation and management (E/M) code 99211 (office or other outpatient visit for the evaluation and management [E/M] of an established patient, that may not require the presence of a physician. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services) for this process. The nurse documented that the patient came in, was evaluated earlier by the urologist, bought the medication and gave it to the nurse to be mixed, and that the nurse gave it back to the patient, explains Natarova. Every time they come back to get a new mixture, we have to charge something for that visit.

Remember that you can charge E/M services only if there is medical necessity. You should not charge just because the patient picks up the medication. Only if you have provided a service that is medically necessary can you bill the 99211.

Coding the Initial Visit and Diagnosis

At the initial visit, the urologist will determine the diagnosis usually either 607.84 (impotence of organic origin) or 302.72 (psychosexual dysfunction with inhibited sexual excitement) (commonly known as erectile dysfunction).

Our urologists will use both diagnosis codes, but a lot of insurance companies dont like the erectile dysfunction diagnosis, explains Radle. They say its a psychological code, and were not psychologists. Nevertheless, any physician can use any ICD-9 code. Pretty much anybody could fall under organic impotence, he says, especially if the patient has just undergone a radical prostatectomy. His physicians sometimes code for erectile dysfunction if it is the appropriate diagnosis, and if an appeal is necessary, Radle will do it.

Natarova notes that Medicare will never pay for treatment if erectile dysfunction is the diagnosis but will pay for impotence of organic origin, 607.84. Impotence is a more serious problem than erectile dysfunction, she notes.

Another diagnosis code that can be used is 607.9 (unspecified disorder of penis), notes Ray Painter, MD, a urologist who is president of PRS, a Denver-based coding and reimbursement consulting firm. If you didnt have a definitive diagnosis, this code would work well, notes Painter.

Coding for Patient Training

If the urologist and the patient agree to try the triple mix treatment, the next step is to teach the patient how to administer the injection. The instruction is performed by a nurse, explains Radle. This is done the same day that the patient comes in for the initial visit. There is no specific code to use for the teaching (which can take anywhere from five to 30 minutes). But there is a code to use for the injection when it is administered in the office (in this case, as part of the teaching). This code is 54235 (injection of corpora cavernosa with pharmacologic agent[s] [e.g., papaverine, phentolamine]). So at the initial visit, the codes would be the appropriate E/M service code, 54235, and one unit each of J2760, J2440, and J0270.

If, for some reason, the teaching is done on a separate day, a nurse visit, (99211), would be billed, as well as 54235, and one unit each of J2760, J2440, and J0270.

Coding for Reversal of Treatment

If the erection lasts for more than two hours, patients are instructed to go to the emergency room or, if the urologists office is open, to the urologist. A drug will be administered that can reverse the effects of the triple mix. The reversal drug is J2370 (injection, phenylephrine HCL, up to 1 ml).